MACRA and AUC: Two Critical Emerging Issues For ACC’s BOG
Periodically the ACC surveys members of its state Chapters to determine the most pressing emerging issues facing cardiovascular medicine. This member feedback helps to shape the agenda of ACC’s Board of Governors (BOG), which serves as the grassroots link between the local Chapters and the broader ACC. The emerging issues survey conducted this past spring focused on the Medicare Access and CHIP Reauthorization Act (MACRA) and procedure denials and test substitutions.
MACRA, which was passed in April 2015, permanently repealed the Sustainable Growth Rate, established a framework for rewarding clinicians for value over volume, streamlined quality reporting programs into one system, and reauthorized two years of funding for the Children’s Health Insurance Program (CHIP). As with many laws, MACRA is written with broad directions that will be implemented through more specific regulations by the federal agencies in the coming months and years. However, educating cardiovascular specialists about this legislation’s complexities and requirements is critical today.
According to the survey, work still needs to be done. Less than one out of three clinicians (30%) report familiarity with the legislation, compared to 66% who are not familiar. Additionally, only one out of five clinicians (19%) state that they are prepared to move away from the current fee-for-service model by 2018 as planned, while 39% are not ready and an additional 42% are not sure. Only 24% of cardiovascular professionals report participation in an alternative payment model. Encouragingly, a majority of clinicians (75%) are interested in learning more about MACRA, with most preferring webinars (77%) over presentations at either chapter meetings (44%) or at ACC’s Annual Scientific Session (36%).
Pre-authorization is another pain point for clinicians with the majority (70%) reporting that pre-authorization has affected their practice by creating delays, increasing overhead and taking time away from patient care and interaction, among other issues. Nuclear procedures are most likely to require pre-authorization (79%), followed by cath (69%), echo (64%), CT (63%) and MRI (59%). Nuclear also receives the highest number of denials, peer-to-peer reviews and appeals. According to clinicians, the primary reasons for procedure denial are “medical necessity not met” (48%) and “alternative test” (45%). Clinicians say that more than three quarters (78%) of denials issued are in conflict with ACC’s appropriate use criteria (AUC).
The vast majority of clinicians surveyed (94%) report addressing pre-authorization problems weekly and nearly all (92%) have staff dedicated solely to the pre-authorization process (with more than 50% having up to three staff members). Unfortunately, most members (72%) tend to be unaware of ACC’s FOCUS decision support tool to help with AUC and pre-authorization issues, and are not currently using any type of decision tool for imaging (85%). However, two out of five (41%) say they would be very likely to use FOCUS or a point-of-care alternative to pre-authorization. Additionally, more than half (55%) of CV professionals indicate that they would be very likely to participate in an ACC initiative to create a database or repository for insurance denials and test substitutions which conflict with ACC Guidelines and AUC.
Interestingly, the Protecting Access to Medicare Act of 2014 (H.R. 4302) includes a provision requiring professionals to consult with AUC through a clinical decision support (CDS) mechanism for all Medicare patients who receive advanced imaging (cardiac nuclear, CT, MR) beginning in January 2018. The ACC was recently informed that it meets requirements to be a qualified “provider-led entity” (PLE) to develop and modify AUC under the Medicare AUC program for advanced diagnostic imaging. According to the Chapter survey, two-fifths of clinicians (39%) are aware of this mandate and three-fifths (59%) are at least somewhat prepared to meet the mandate.
The College is committed to keeping its members informed and educated about MACRA, with a content-rich online hub located at ACC.org/MACRA. In addition, members seeking more information about the FOCUS tool and issues surrounding pre-authorization and the AUC Mandate can visit ACC.org/FOCUS.
Keywords: Medicare Access and CHIP Reauthorization Act of 2015
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